The combination is a useful and viable option for patients who need chemoradiation but cannot tolerate cisplatin or other types of chemotherapy, added Dr. Cohen. For the many patients who are elderly or have poor kidney function or other significant comorbid conditions such as heart failure or diabetes, cetuximab with radiation provides a more effective treatment option than radiation alone and is well tolerated.
Explore This IssueMay 2006
The blanket statement that chemoradiation therapy is the standard of care for advanced disease is troublesome for me, said Dr. Strome. Stage 3 cancers, for example, can have small primary tumor sites that can be treated with endoscopic surgery, while avoiding the side effects of chemoradiation.
More and more head and neck surgeons are doing endoscopic surgery for small primary lesions in the voice box and pharynx, said Dr. Strome. For example, some patients with T-2 lesions of the larynx with a positive neck node can be out of the hospital in five days, and talk and swallow within two weeks.
The problem is, a lot of people don’t understand what modern surgery can accomplish as opposed to 10 years ago, he said. I can take a small tumor out through the mouth with a laser and cryotherapy. While not all centers offer this treatment, patients need to understand it is an option.
Impact on the Otolaryngologist’s Role
The impact of cetuximab and other biological agents on otolaryngologist-head and neck surgeon’s role in providing care for head and neck cancer patients is significant, said Robert Dolan, MD, Senior Staff in the Lahey Clinic Medical Center’s Department of Otolaryngology-Head and Neck Surgery in Burlington, Mass.
While the agent appeared to be beneficial for oral pharyngeal cancer, it did not make any difference in outcomes in patients with larynx or hypopharyngeal cancer.
Counseling the patient regarding prognosis may be impacted, he said. For example, if the outcome of the phase III clinical trials using cetuximab is positive as anticipated, then the otolaryngologist may justifiably predict an improved outcome with regard to tumor control and ultimately survival, he explained.
The otolaryngologist will also need to be aware of the potential side effects of cetuximab. In the long term, there is a potential for these biologic agents to supplant standard chemotherapy either as single agents or more likely as multiple agents targeting unique pathways of tumor growth and spread, he said.
Patients need to be given the various options that are available to them, said Dr. Strome. Physicians should let patients know the side effects of radiation, the potential 10% improvement in survival at three years with cetuximab and how these therapies compare with surgery. Chemotherapies are also becoming more effective, he said.